A nurse is using SOAP documentation to write a progress note for a client who has cellulitis of the lower leg.

The nurse needs to select all that apply when writing an assessment entry in SOAP documentation.

Redness, swelling, and warmth of the affected area.

Pain level rated as 8/10 on a numerical scale C.

Wound culture results pending.

Risk for infection related to impaired skin integrity.

Applied moist heat compresses to the wound site.

Answer and Explanation

Correct Answer : A,B

These are the only options that describe the subjective and objective data of the patient, which are part of the SOAP documentation method. SOAP stands for Subjective, Objective, Assessment, and Plan, and it is a way of recording patient data in a clear and consistent manner.

Choice C is wrong because wound culture results are not part of the assessment entry in SOAP documentation. They are part of the investigation results, which are usually documented in the objective section.

Choice D is wrong because risk for infection related to impaired skin integrity is a nursing diagnosis, not an assessment. Nursing diagnoses are usually documented in the plan section of SOAP documentation.

Choice E is wrong because applied moist heat compresses to the wound site is an intervention, not an assessment. Interventions are also documented in the plan section of SOAP documentation.

Normal ranges for vital signs are as follows:.

• Blood pressure: 90/60 mmHg to 120/80 mmHg.

• Pulse rate: 60 to 100 beats per minute.

• Respiratory rate: 12 to 20 breaths per minute.

• SpO2: 95% to 100%.

• Temperature: 36.5°C to 37.5°C.

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Correct Answer is ["A","B","D","E"]

Explanation

A. Log off the system when leaving the workstation.

This is a correct action to ensure confidentiality and security of electronic health records (EHRs).

Logging off prevents unauthorized access to client information by other users who may use the same workstation.It also protects the system from malware or cyberattacks that may compromise the data integrity or availability.

B. Shred any printouts before discarding them.

This is also a correct action to ensure confidentiality and security of EHRs.

Shredding any printouts that contain client information prevents them from being accessed by unauthorized persons who may find them in the trash or recycling bins.It also complies with the legal and ethical obligations to protect the privacy of clients.

C. Use a personal digital assistant (PDA) to access client information.

This is an incorrect action to ensure confidentiality and security of EHRs.

Using a PDA to access client information may expose the data to unauthorized access, loss, theft, or damage.

PDAs are typically not encrypted or password-protected, and may not have adequate security features or software updates to prevent cyberattacks or malware infections.PDAs may also not be compatible with the EHR system or follow the data standards and interoperability requirements.

D. Change the password at regular intervals.

This is another correct action to ensure confidentiality and security of EHRs.

Changing the password at regular intervals reduces the risk of password cracking, guessing, or phishing by unauthorized users or hackers.It also helps to maintain the accountability and authentication of authorized users who access the EHR system.

E. Report any breaches or attempted breaches to the appropriate authority.

This is also a correct action to ensure confidentiality and security of EHRs.

Reporting any breaches or attempted breaches to the appropriate authority helps to identify and mitigate the impact of any data loss, corruption, or disclosure.It also helps to comply with the legal and regulatory obligations to notify the affected clients and stakeholders, and to prevent further breaches or incidents.

A. It eliminates errors and inaccuracies in documentation. B. It allows access to client information from multiple locations. C. It reduces the need for verbal or written communication among health care providers. D. It protects client information from unauthorized disclosure or alteration.

Correct Answer is B

Explanation

It allows access to client information from multiple locations.

This is an advantage of using a computerized system for documentation and reporting because it enables health care providers to access relevant and updated information about their clients from different locations, such as hospitals, clinics, or home care settings.This can improve the quality and continuity of care, as well as facilitate communication and collaboration among different members of the health care team.

Choice A is wrong because it is not true that a computerized system eliminates errors and inaccuracies in documentation.While a computerized system can reduce some types of errors, such as illegible handwriting or misplaced files, it can also introduce new types of errors, such as data entry mistakes, software glitches, or system failures.

Choice C is wrong because it is not true that a computerized system reduces the need for verbal or written communication among health care providers.On the contrary, a computerized system can enhance communication by allowing health care providers to share information more easily and quickly, but it does not replace the need for verbal or written communication to clarify, confirm, or discuss the information.

Choice D is wrong because it is not true that a computerized system protects client information from unauthorized disclosure or alteration.

While a computerized system can provide some security features, such as passwords, encryption, or audit trails, it can also pose some risks, such as hacking, phishing, or malware attacks.Therefore, health care providers need to follow ethical and legal guidelines to ensure the confidentiality and integrity of client information in a computerized system.

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A nurse is using SOAP documentation to write a progress note for a client who has cellulitis of the lower leg. The nurse needs to select all that apply when writing an assessment entry in SOAP documentation.

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Naxlex Comprehensive Predictor Exams

A nurse is using a computerized documentation system in a health care facility. Which of the following actions should the nurse take to ensure confidentiality and security? (Select all that apply.).

Correct Answer is ["A","B","D","E"]

Explanation

What is one advantage of using a computerized system for documentation and reporting?

Correct Answer is B

Explanation

Which of these statements about documentation are true? (Select all that apply.).

A nurse is using focus charting to document a client’s progress notes. What are the advantages of using focus charting? (Select all that apply.).

A nurse is preparing to report a change in a client’s condition to another health care provider. What should the nurse include in the report?

A nurse is taking a telephone order from a radiologist for a client who needs an urgent chest x-ray. Which of the following statements by the nurse is correct for verifying the order?

A nurse is using SOAP format to document a client’s progress note. What does SOAP stand for?

A nurse is using the focus charting method to document care for a client who has diabetes mellitus. Which of the following terms should the nurse use to begin each entry?

A nurse is participating in a care plan conference for a client who has multiple chronic conditions and complex care needs. What is the main purpose of this meeting?

A nurse is reviewing the record system used in an agency. Which of the following types of records are used for documenting concise data about a client and making information quickly accessible to all health professionals? (Select all that apply.).

A nurse is using SOAP documentation to write a progress note for a client who has cellulitis of the lower leg.

The nurse needs to select all that apply when writing an assessment entry in SOAP documentation.